Contralateral sialadenitis after resection of a right cerebellar metastasis: illustrative case

BACKGROUND Acute postoperative sialadenitis is a rare and potentially morbid complication of cranial neurosurgery. This rapidly progressive, unilateral neck swelling often presents within hours of extubation. Diagnosis is made by imaging and exclusion of other causes of etiologies, such as neck hematoma, sialolithiasis, and dependent soft tissue edema. OBSERVATIONS The authors presented a case of acute postoperative sialadenitis after suboccipital resection of a right cerebellar metastasis. Shortly after extubation, extensive left-sided neck swelling was apparent in the postanesthesia care unit. No central lines were placed during the procedure. Imaging revealed submandibular gland edema and fluid accumulation in the surrounding tissue. The patient was managed conservatively with steroids, antibiotics, and warm compresses, with complete resolution of symptoms 2 weeks after the procedure. LESSONS This case emphasizes the broad differential of acute neck swelling after cranial surgery. Physical examination of the neck and airway protection should guide initial treatment. If a patient is stable, bedside ultrasound and computed tomography can be helpful with the differential diagnosis. Here the authors proposed an algorithm for diagnosis and treatment of acute neck swelling after cranial surgery.

Mechanical Ventilation in Neurocritical Patients

Patients under neurocritical care may require mechanical ventilation for airway protection; respiratory failure can occur simultaneously or be acquired during the ICU stay. In this chapter, we will address the ventilatory strategies, in particular the role of protective lung ventilation, and the potential increase in intracranial pressure as a result of permissive hypercapnia, high airway pressures during recruitment maneuvers, and/or prone position. We will also describe some strategies to achieve mechanical ventilation liberation, including evaluation for tracheostomy, timing of tracheostomy, mechanical ventilation modalities for weaning and extubation, or tracheostomy weaning for mechanical ventilation.

A Chemist with a Strange Etiology of Rhabdomyolysis: A Case Report of a Rare Toxicological Emergency

Introduction: Chloroform, a halogenated hydrocarbon, causes central nervous depression, hepatotoxicity, nephrotoxicity, and rhabdomyolysis. Historically, chloroform had been used as a general anaesthetic and today is still used in chemical industries. Lack of proper personal protective equipment and adequate knowledge about its toxic effects can lead to serious harm. Case report: A 33-year-old gentleman presented to the emergency department (ED) with altered mental status. Given his depressed mental status, the decision was made to intubate shortly after arrival for airway protection. Further history raised suspicion of occupational chloroform exposure. Brown-colored urine further strengthened suspicion of chloroform poisoning with resultant rhabdomyolysis. Forced alkaline diuresis and N-acetylcysteine were started in the ED. His mental status and respiratory efforts improved on hospital day two, and he was ultimately extubated. Creatine phosphokinase and myoglobin levels were initially high but gradually came down by hospital day six. On hospital day 10, the patient was deemed stable and safely discharged. Conclusion: A patient with chloroform inhalation who suffered resultant rhabdomyolysis and hepatotoxicity was successfully treated with early initiation of forced alkaline diuresis, N-acetylysteine, and hemodialysis.

Outcomes Associated with Lower Doses of Ketamine by Emergency Medical Services for Profound Agitation

Introduction: Ketamine is commonly used to treat profound agitation in the prehospital setting. Early in ketamine’s prehospital use, intubation after arrival in the emergency department (ED) was frequent. We sought to measure the frequency of ED intubation at a Midwest academic medical center after prehospital ketamine use for profound agitation, hypothesizing that intubation has become less frequent as prehospital ketamine has become more common and prehospital dosing has improved. Methods: We conducted a retrospective cohort study of adult patients receiving ketamine in the prehospital setting for profound agitation and transported to a midwestern, 60,000-visit, Level 1 trauma center between January 1, 2017–- March 1, 2021. We report descriptive analyses of patient-level prehospital clinical data and ED outcomes. The primary outcome was proportion of patients intubated in the ED. Results: A total of 78 patients received ketamine in the prehospital setting (69% male, mean age 36 years). Of the 42 (54%) admitted patients, 15 (36% of admissions) were admissions to the intensive care unit. Overall, 12% (95% confidence interval [CI]), 4.5-18.6%)] of patients were intubated, and indications included agitation (n = 4), airway protection not otherwise specified (n = 4), and respiratory failure (n = 1). Conclusion: Endotracheal intubation in the ED after prehospital ketamine use for profound agitation in our study sample was found to be less than previously reported.

Post traumatic near total amputation of apex of tongue: a rare case report

Post traumatic near total amputation of apex of tongue is a rare scenario but when happens it causes life threatening situation due to active intraoral bleeding and risk of aspiration especially in children. Tongue is a unique organ which has very rich blood supply and resides in intraoral cavity. Due to its rich blood supply profuse bleeding is commonly seen after the tongue injury. It helps in swallowing, speech, taste, mastication and airway protection. It facilitates perception of gustatory stimuli. Here author presents a case of 13 months old female child, who presented to emergency department with history of fell down from the bed and sustained tongue injury with profuse bleeding. On examination patient had near total amputation of apex of tongue. Gentle debridement followed by meticulous complex repair of intrinsic muscles of tongue was done. On post-operative day two patient was discharged uneventfully.

Acute Profound Thrombocytopenia Induced by Eptifibatide Causing Diffuse Alveolar Hemorrhage

Background. Eptifibatide is a glycoprotein IIb/IIIa (GP IIb/IIIa) receptor inhibitor which prevents platelet activation. The mechanism in which eptifibatide causes profound thrombocytopenia is poorly understood. One hypothesis suggests antibody-dependent pathways which cause thrombocytopenia upon subsequent reexposure to eptifibatide. This case reports acute profound thrombocytopenia ( platelets < 20 × 10 3 / m m 3 ) within 24 hours of administration. Alveolar hemorrhage occurred during a second eptifibatide infusion 5 days after initial asymptomatic eptifibatide treatment. Case Presentation. A 50-year-old male presenting with a STEMI was treated with eptifibatide during cardiac catheterization. Twelve hours posttreatment, the patient encountered profound thrombocytopenia and hemoptysis. The patient was briefly intubated for airway protection. The patient was stabilized after receiving platelet transfusion and fully recovered. Conclusion. This is one of several cases reported on eptifibatide causing acute profound thrombocytopenia and subsequent alveolar hemorrhage. This case supports the theory in which antibodies contribute to eptifibatide-induced thrombocytopenia.

Adolescent and adult laryngotracheal stenosis: a review

Background The larynx has multiple composite functions which include phonation, airway protection, and sensory control of respiration. Stenosis of the larynx and trachea were first recorded by O’Dwyer in 1885 and by Colles in 1886, respectively. Initially, the aetiology of laryngotracheal stenosis was predominantly infective. Currently, the leading cause is iatrogenic injury to the laryngotracheal complex secondary to prolonged ventilation in an intensive care unit. Main body Laryngotracheal stenosis is a complex and diverse disease. It poses a major challenge to the surgeon and can present as an airway emergency. Management typically demands the combined involvement of various disciplines including otorhinolaryngology, cardiothoracic surgery, anaesthesiology, interventional pulmonology, and radiology. Both the disease and its management can impact upon respiration, voice, and swallowing. The incidence of iatrogenic laryngotracheal stenosis has reflected the evolution of airway and intensive care whilst airway surgery has advanced concurrently over the past century. Correction of laryngotracheal stenosis requires expansion of the airway lumen; this is achieved by either endoscopic or open surgery. We review the relevant basic science, aetiopathogenesis, diagnosis, management, and treatment outcomes of LTS. Conclusion The choice of surgical procedure in the management of laryngotracheal stenosis is often dictated by the individual anatomy and function of the larynx and trachea, together with patient factors and available facilities. Regardless of how the surgeon chooses to approach these lesions, prevention of iatrogenic laryngotracheal damage remains of primary importance.

“You can leave your mask on”: effects on cardiopulmonary parameters of different airway protection masks at rest and during maximal exercise

BackgroundDuring the COVID-19 pandemic, the use of protection masks is essential to reduce contagions. However, public opinion reports an associated subjective shortness of breath. We evaluated cardiorespiratory parameters at rest and during maximal exertion to highlight any differences with the use of protection masks.MethodsTwelve healthy subjects underwent three cardiopulmonary exercise tests: without wearing protection mask, with surgical and with FFP2 mask. Dyspnea was assessed by Borg Scale. Standard pulmonary function tests were also performed.ResultsAll the subjects (40.8±12.4 years; 6 males) completed the protocol with no adverse event. At spirometry, from no mask to surgical to FFP2, a progressive reduction of FEV1 and FVC was observed (3.94±0.91 l, 3.23±0.81 l, 2.94±0.98 l and 4.70±1.21 l, 3.77±1.02 l, 3.52±1.21 l, respectively, p<0.001). Rest ventilation, O2 uptake (V̇O2) and CO2 production (VCO2) were progressively lower with a reduction of respiratory rate. At peak exercise, subjects revealed a progressively higher Borg scale when wearing surgical and FFP2. Accordingly, at peak exercise, V̇O2 (31.0±23.4, 27.5±6.9, 28.2±8.8 ml/kg/min, p=0.001), ventilation (92±26, 76±22, 72±21 l, p=0.003), respiratory rate (42±8, 38±5, 37±4, p=0.04) and tidal volume (2.28±0.72, 2.05±0.60, 1.96±0.65 l, p=0.001) were gradually lower. We did not observed a significant difference in oxygen saturation.ConclusionsProtection masks are associated with significant but modest worsening of spirometry and cardiorespiratory parameters at rest and peak exercise. The effect is driven by a ventilation reduction due to an increased airflow resistance. However, since exercise ventilatory limitation is far from being reached, their use is safe even during maximal exercise, with a slight reduction in performance.

Unusual cause of acute upper airway obstruction: spontaneous pharyngeal haematoma

Spontaneous pharyngeal haematoma is a rare but life-threatening cause of acute upper airway obstruction, and the clinical manifestation may mimic haemoptysis. A 65-year-old man presented to our emergency department with symptoms of sore throat and haemoptysis. He had no medical history. At arrival, O2 saturation was 95% on 5 L/min of oxygen with a mask. Results of a blood examination including a coagulation test were normal. Laryngoscopy showed enlargement of the left pharynx and a narrowed airway. Contrast-enhanced CT showed extravascular leakage of contrast medium inside the left pharyngeal haematoma. Fortunately, the haematoma did not lead to airway obstruction, and it decreased spontaneously. We finally diagnosed this case as spontaneous pharyngeal haematoma. When we examine a patient with a symptom of haemoptysis accompanied by sore throat, it is necessary to consider pharyngeal haematoma and to prepare emergency airway protection for acute upper airway obstruction.

Cervical edema after anterior cervical fusion, a rare but potentially fatal complication: a case report

<p>Anterior approaches to the cervical spine can be performed for spine decompression and instrumentation in many pathologic conditions. Cervical spine surgeries complicate in 5.3% of cases, with anterior procedures representing 65% of them. Airway compromise requiring tracheostomy or reintubation is rare but may lead to potentially catastrophic complications. There are several causes for airway compromise, including post-operative cervical swelling or hematoma, pharyngeal edema, cerebrospinal fluid (CSF) leak, angioedema, and graft or implant displacement. We present a case of a 57-year-old male with chronic neck and left radicular pain. He was submitted to C5-C6 anterior cervical disc fusion that was complicated with airway compromise in the orthopedics ward. The patient required emergent reintubation for airway protection, wound exploration and intensive care. Hematoma is often the first diagnosis to consider in the immediate postoperative period. A low threshold for intubation should be maintained. After airway protection, it is essential to differentiate etiologies, to guide subsequent management.</p><p><strong> </strong></p>